Plateau Therapy……a thing of the past
Author: Barbara (Bobbi) Kolonay RN, MS, CCM Aging Life Care Manager in Pittsburgh PA
You should no longer hear the words “I’m sorry, but you are no longer continuing to make progress in Physical Therapy (Occupational Therapy, Speech Therapy) so we need to discharge you from our service”, coming from your client’s therapist.
The Jimmo settlement was approved on January 24, 2013 after a fairness hearing. The lawsuit was brought on behalf of a nationwide class of Medicare beneficiaries by six individual beneficiaries and seven national organizations representing people with chronic conditions, to challenge the use of the illegal Improvement Standard.
As CMS states in the Transmittal announcing the Jimmo Manual revisions:
No “Improvement Standard” is to be applied in determining Medicare coverage for maintenance claims that require skilled care. Medicare has long recognized that even in situations where no improvement is possible, skilled care may nevertheless be needed for maintenance purposes (i.e., to prevent or slow a decline in condition). The Medicare statute and regulations have never supported the imposition of an “Improvement Standard” rule-of-thumb in determining whether skilled care is required to prevent or slow deterioration in a patient’s condition. Thus, such coverage depends not on the beneficiary’s restoration potential, but on whether skilled care is required, along with the underlying reasonableness and necessity of the services themselves. The manual revisions now being issued will serve to reflect and articulate this basic principle more clearly. [Emphasis in original.]
The settlement of a class action lawsuit means Medicare is prohibited in denying coverage for Skilled Nursing Therapy, Home Health Care or Outpatient Therapy because the person has reached a “plateau,” and the physical condition was not improving. This is especially beneficial to our clients with cognitive disorders who would “forget” what they had learned in PT from the previous session and thereby be denied SNF and Home Health Care coverage.
WHAT THIS MEANS FOR A SENIOR NEEDING THERAPY
This settlement should help to improve the lives of many of our clients who were previously denied therapy with Alzheimer’s disease, Parkinson’s, CVA, and Chronic Debilitating health issues. What we have seen for most of our client’s is every time they stop therapy, they start to backslide in balance, mobility, and strength despite our best efforts. Not only does this ruling provide much needed benefit covered services but allow them to age-in-place in their home or assisted living environment, preventing a costly skilled nursing placement. Additionally, if skilled nursing is needed for therapy, Medicare can no longer deny it based on that their condition was not improving.
- For seniors receiving therapy at home that means coverage has no time limit but the person still must be home bound and need intermittent care only a therapist can provide
- This also assures seniors requiring therapy to qualify for SNF rehabilitation regardless of improvement, and continues to have the 100 day/benefit period stipulation
- Advocate for your client to have benefits extended using the above guidelines, realizing there may be a 2 week interruption in therapy while the therapist waits for Medicare approval
- Amazingly, there are still therapy providers and SNF’s who are not aware of this change; carry a copy of this around with you to educate:
Bobbi (Barbara) Kolonay RN BSN MS CCM
Fellow of the Leadership Academy Aging Life Care Association
President of: HOLISTIC AGING & OPTIONS FOR ELDER CARE
4284 Route 8 Ste #103
Allison Park PA 15101
(Originally published on November 14th, 2014)